Bridgend Community Weight Management Programme 18 July 2012 Welsh Public Health Conference Presenters: Peter Mannion, Beth Preece ABM Public Health Team and Dr Sean Young (GP/ CD for Primary Care Bridgend)

How it started Initiated by GP in Cwm Garw Practice with support from chronic conditions management in HB Perception of need due to – Increase in prescribing of anti-obesity medication (and limited effectiveness) Lack of community based provision

Level two of the All-Wales Obesity Pathway Specialist medical and surgical services Targeted gateway one to one MDT Level 3 Specialist MDT Weight Management Services Targeted gateway- dietetic and physical activity support Community and Primary Care Weight Management Services Level 2 Targeted Gateway – Community Intervention for Overweight/Obesity Primary care has been recognised as a potentially important setting for the promotion of healthy lifestyles and healthy weight. Each appointment provides an opportunity to promote behaviour change or to refer patients to relevant support services. The Welsh Assembly Government (2010) set out an All-Wales Obesity Pathway, which is a tool for Health Boards, working jointly with Local Authorities and other key stakeholders, to map local policies, services and activity for both children and adults against four tiers of intervention and to identify any gaps. Level two of the All-Wales Obesity Pathway focuses on community and primary care weight management services, the aim of this level is to ensure availability of a range of services for children, young people and adults who wish to lose weight and have been identified as being at increased risk of obesity by a member of the primary care team. It suggests local best practice to ‘Implement an evidence based adult weight management programme in community or primary care.’ If individuals require further support to achieve and maintain a healthy boy weight than the level 1 service provide then a targeted community intervention should be in place to try to prevent these individuals from moving to level 2. Level 2 Community and primary care weight management services The aim of this level is to ensure availability of a range of services for children, young people and adults who wish to lose weight and have been identified as being at increased risk of obesity by a member of the primary care team. People who are ready to change will be supported by a trained individual. Evidence suggests that a ‘best fit’ individual approach is more beneficial because it can ensure that the individual is willing to change and the type of intervention is suited to the individual. Dietetic and physical activity weight management intervention. If individuals require further support to achieve and maintain a healthy body weight than the level2 a targeted dietetic and physical activity weight management intervention should be in place to try to prevent these individuals from moving to level3. NICE (2006) guidance states that recommendations or endorsements to self-help, community and commercial weight management programme should only be considered to those that follow best practice. Best practice was outlined as: Helping people assess their weight and decide on a realistic health target weight (people should usually aim to lose 5-10% of their original weight) Aiming for a maximum weekly weight loss of 0.5kg-1kg Focusing on long-term lifestyle changes rather than a short term, quick fix approach Being multi-component, addressing both diet and activity, and offering a variety of approaches Using a balanced, healthy eating approach Recommending regular physical activity (particularly activities that can be part of daily life, such as brisk walking and gardening) and offering practical, safe advice about being more active Including some behaviour change techniques, such as keeping a diary and advice on how to cope with lapses and high-risk situations Recommending and / or providing ongoing support. Community based prevention and early intervention (Self Care) Level 1

NICE Guidelines (2006) It is unlikely that the problem of obesity can be addressed through primary care management alone The clinical management of obesity cannot be viewed in isolation from the environment in which people live. Multicomponent interventions are the treatment of choice: behaviour change strategies to increase people's physical activity levels and improve eating behaviour

NICE Guidelines (2006) Weight loss programmes (including commercial or self-help groups, slimming books or websites) are recommended only if they: are based on a balanced healthy diet encourage regular physical activity expect people to lose no more than 0.5–1 kg (1–2 lb) a week.

Community Based Model Exercise on Referral Community Weight Group Primary Care Leadership Assess motivation GP contract Monitoring Community Weight Group Set target weight, Monitor weight Peer support Weekly discussion topics Exercise on Referral Provision of structured programme of physical activity under guidance of suitable qualified exercise professional Community Wellbeing Broker Signposting Motivating Supporting engagement A multiagency partnership is involved in this programme comprising of: Cwm Garw surgery General Practitioners, Practice Nurse, Practice Manager Abertawe Bro Morgannwg Primary Care Planning Support Manager Bridgend Public Health Team, Public Health Wales Bridgend County Borough Council, Wellbeing Directorate, Exercise Referral Team Weight Watchers Area Service Team. The programme was supported by the Locality Associate Medical Director and Locality Management Board as part of service review and evaluation Objectives: To provide an appropriate community based accessible weight management programme For participants to reduce at least 5% of weight during first 12 weeks of the programme For participants to reduce one or more of the following cardiovascular parameters: blood pressure, cholesterol, Hba1c For participants to maintain healthy lifestyle changes during and after the project and sustain them in the longer term through integrating with other services available in the community For the GP practice to reduce its prescribing levels of anti-obesity medication. Aim: to provide a community weight management programme delivered in a non-clinical environment that gives individuals support to make sustainable changes to their lifestyle and reduce prescribing of anti-obesity medication.

The Pathway Activities Practice Nurse refers, conducts baseline assessment and monitors patients Attendance at 12 weeks on Weight Watchers Referral Pack Attendance at 16 week exercise on referral programme Wellbeing Broker supports engagement with community based activities to facilitate sustainable lifestyle change The GP’s inform eligible patients about the programme, either during routine consultation or when they make an appointment with concerns about their weight. The Practice agrees to make no new prescriptions for Orlistat, unless the programme has been considered and those already prescribed are encouraged the switch to the programme. Those patients that are motivated sign a commitment contract with the GP practice, they are then given vouchers for Weight Watchers and a referral is made to the exercise referral team. Throughout the programme GP practices continue to manage and monitor the patient.

Service Evaluation Method Mixed method approach (real life context): Satisfaction – 3 patient stories Constraints and supporting factors to maintaining a behaviour change – Wellbeing Wales Wellbeing Assessment (focus groups and questionnaires) Cardiovascular parameters measured and self report healthy eating and quality of life questionnaire for 66 pilot participants and analysed by Swansea University Monitoring of prescribing levels of weight loss medication (Orlistat)

Research Evidence Jebb et al ‘commercial weight loss programme- clinically useful early intervention for weight management in overweight and obese people that can be delivered at large scale’ Lancet 2011 Jolly et al- ‘Commercially provided weight management services are more effective and cheaper than primary care based services led by specially trained staff, which are ineffective’ BMJ 2001 Commercial slimming companies: BBC diet trials (Truby et al, 2006) – 7.3% weight loss at 6 months in Weight Watchers Group Literature review Tsai and Wadden (2005) – results of US commercial and organised self help weight loss programmes struggle to reach clinical effectiveness, one RCT demonstrated efficacy Participants referred to commercial weight loss programme lost twice as much weight at 12 months, and were three times more likely to lose more than 5% initial weight, than those receiving standard care (Jebb et al, 2011, parallel group, non-blinded, RCT ) RCT of 8 study groups including 3 commercial, 3 NHS weight loss, patient choice and minimal intervention – all achieved statistically significant weight loss at 3 months, almost a third achieved 5% weight loss at 12 months (Jolly et al, 2011) Public Health Wales (2011) Literature Review Limitations of these studies: Diet trials compared four different commercial programmes with a control not with routine care. Jebb et al - High attrition rates Non-blinded Participants did not pay which for up to 12 months which is not realistic for NHS Jolly et al – real service context, self reported measures of weight and PA where objective measures not available, initial uptake low (of 8810 eligible, 11.5% joined), which most likely to be those that are most motivated and may have led to bias Public Health Wales undertook lit review before publication of Jebb et al and Jolly et al. It concluded that “Commercial weight management programmes can help some individuals to lose some wieght, sometimes a clinically significant amount, in the short term. However, there is a lack of significant and consistent effect in the longer term.” Complex nature of measuring impact. Limitations of study. Longer term weight loss and maintenance is the gap in evidence base. Exercise Referral: The Welsh Assembly Government commissioned an independent evaluation of the scheme as it rolled out in 12 of the 22 LHB in Wales, utilising a randomised controlled trial design. 2,160 inactive men and women aged 16 and over with coronary heart disease (CHD) risk factors and / or mild to moderate depression, anxiety or stress were recruited. Participants were stratified by gender and LHB and randomised to the scheme (intervention), or received an information booklet on physical activity and normal GP care (control). For all participants, those in the intervention group for participants referred with CHD risk factors only, there was a significantly increased likelihood of increases in physical activity and a statistically significant. Public Health Wales – Health Trainers Rapid Review – not yet published - The health trainer approach uses the practical skills, capacity and knowledge of local residents to support people in changing their behaviour. The available evidence neither supports nor refutes the use of such programmes in supporting people to change their behaviour and adopt healthier lifestyles.

Progress Launched Cwm Garw Practice September 2010 , Ogmore Vale March 2011, Nantymoel June 2011 372 total number of participants Average age 48 years (min 18 – max 81) Average BMI at start 38.6kg/m2 Average BMI at end (for those that complete 24 weeks) – 35.2kg/m2 81% completing 10 weeks or more of Weight Watchers 58% taking up exercise on referral, most popular activities walking, gym and exercise class (e.g. Zumba)

Results Statistically significant mean weight loss – 7.2kg Statistically significant mean BMI reduction – 7% Statistically significant reduction in waist circumference 58 % (25) achieved 5% or more weight loss at twelve weeks Diabetic cohort (15) achieved the most health benefits with greater mean weight loss and significant reduction in Hba1C Reductions in blood pressure and cholesterol but not significant

Prescribing Poor Tolerability Poor Efficacy £94.89 VS £48.50 FOR 12 WEEKS

Patient Story “They said if my blood sugar didn’t come down I was going to be put on insulin. I didn’t want to be a pincushion, so when they suggested WeightWatchers, I said I would give it a go” For my diabetes, they’ve stopped everything bar two tablets where I used to have eight” hba1c 8.2% on gliclazide/ metformin hba1c 6.1% on metformin alone bmi 45 to 37 (weight loss 18kg)

Patient Story “My blood pressure was high and I’ve got asthma and arthritis. My blood pressure tablets have now stopped. I still have aches and pains, but after losing three stone I feel good about myself” wt loss on orlistat 3/12- 1kg wt loss on scheme 3/12- 7kg bmi 44 now 38 (weight loss 14kg) felodipine 10mg/ perindopril 4mg – both stopped- bp satisafactory of medication

Patient Story “When I lost the weight, one of the first things I did was come off painkillers. I’m still on blood pressure tablets, but it’s under control, my cholesterol is good, my pain has gone, I’m moving easier and sleeping” bmi 45 now 31 (weight loss 31.5kg)

Wellbeing Results The following are supportive of participants subjective wellbeing: - being part of a group or community a supportive co-ordinator, family and friends being able to take control of weight recognising physical and medical benefits The role of the environment in supporting wellbeing could be enhanced

Lessons Learnt Requires primary care ownership to actively manage patient compliance and review contract between patient and GP practice Individuals require support to make sustainable lifestyle changes which have to be relevant to their life within their community The focus needs to be that this is a healthy lifestyle programme and not a diet Developing and maintaining the links between components requires a strong sustained collaborative effort Careful consideration of data collection protocols from the outset is very important especially when data will be used from different organisations; retrospective collation is difficult. The focus will now turn to: Develop business case for rolling out to Bridgend locality Demand could be very high Each programme is entirely specific to the community context and support available in that community the maintenance of weight and healthy lifestyle changes over at least a 12 month basis Lles Cymru / Wellbeing Wales have been commissioned to carry out a wellbeing assessment of the larger cohort of participants. It will bring rich data about the perceptions of participants about the appropriateness of the programme and the constraints and supporting factors to maintaining the behaviour change increasing uptake of exercise on referral Bay Health Network in Swansea is piloting a scheme for diabetics only, these findings when available will enable the eligibility criteria to be re-considered.

Future Plans Roll-out to other GP practices in Bridgend Assessing the longer term sustainability of this programme – monitoring of weight and cardiovascular parameters up to 12 months Build evidence of cost effectiveness through prescribing savings Increasing uptake to exercise on referral Further development and evaluation of the Wellbeing Broker role Agree place within pathway

Feedback from the NHS Wales Awards Judges: “This is a creative, yet practical, response to the health and well-being needs of the local community – and it made a real and tangible difference to the lives of the participants, and in turn to their families. This clearly set out to address health inequalities and succeeded in introducing new ways of thinking about lifestyle, improving health and avoiding disease.”

Any Questions?

Discussion How important do you feel is a level 2 weight management programme compared to actions at other levels of the obesity pathway, to make the most impact on obesity levels?

What type of evidence would you want to support a programme like this?

What would need to be considered? How transferable do you feel the Bridgend Community Weight Management Programme is to other communities? What would need to be considered?

Are there other effective options for providing support at level two- which can deliver volume and efficacy?